My patient today is Ms Martha Vineyard, she is a 71 year old Caucasian female, DOB 3/13/1940. Today is her first visit to our clinic and her chief complaint is her implant is falling out.
Ms Vineyard had her implant placed 9 months ago and had the crown seated 6 months ago with her general dentist in Florida. Ms Vineyard lives in Florida half of the year and in California the other half. Her dentist of record in California retired and she did not care for the new dentist that bought the practice. Ms Vineyard has periodontal maintenance every 4 months. She had an FMX when the crown for her implant was seated 6 months ago and brought a duplicate set with her to the appointment. Her last perio maintenance in Florida was before she had the implant restored and reported that since the crown has been placed 6 months ago, she has not been in for a cleaning due to trying to find a new dentist in California.
Ms Vineyard also wears a lower partial denture that she reports is not fitting like it used to and she has a sore spot on the most anterior aspect of the mandibular ridge.
Ms Vineyard has a history of bleeding gums spontaneously and has cold temperature sensitivity on her maxillary teeth due to recession. She has nonpainful clicking and popping bilaterally, she has had it all her life. She has a history of periodontal surgery on the maxillary arch 10 years ago. She has been wearing her lower partial denture for over 20 years.
Ms Vineyard has no past or present cardiovascular conditions, respiratory condtions, head and neck conditions, gastrointestinal/genitor-urinary conditions.
Ms Vineyard stated she bruises easily and has a history of pernicious anemia. She is presently under the care of her physician in Florida for her anemia diagnosed in 2001; treated with vitamin B12 injections as needed and monitored. Pt stated currently under control and is on a special diet high in fish, cheese, milk, and eggs. She also had breast cancer when she was 51 years old and had chemotherapy and radiation treatment and ultimately had her left breast removed 6 months after her diagnosis with breast cancer and has been in remission since.
She denies having any past or present psychological disorders has never smoked/drank/or taken any drugs. She had her childhood vaccinations later in life when she was in college preparing to be a teacher, including the hepatitis B vaccination series. She had her last flu shot in Sept. 2011. She is not menopausal nor takes any hormones.
Her family has a history of heart disease, her father died at young age from a heart attack. Her mother passed from lung cancer.
Ms Vineyard has no allergies to anything and doesn’t have any additional medical information to share.
She was hospitalized on and off when she was 51 for the chemo and radiation treatment and surgery of the removal of her left breast for cancer within a 6 month period.
She was seen in the emergency room for a sprained ankle when she tripped in a grocery store parking lot at night last year. She made a full recovery.
Ms Vineyard takes 81 mg Aspirin daily.
S: Pt stated she is here for “her implant is falling out.”
O: RMH initial visit. B.P. 114/68, P. 71, R. 15. E & I bilateral linea alba, palatal torus, and fordyce granules on lower lip and buccal mucosa of lower lip.
A: ASA II. ADA II with localized ADA III on implant #19. AAP class generalized slight chronic periodontitis and localized moderate chronic periodontitis due to plaque and calculus. MVC Cal Code light/medium.
P: Gathered assessments, x-ray check, took one PA of #19 implant. DDS Exam, 2nd Check-in, PI/OHI. Referral given to patient to see Periodontist specialist for the evaluation of periimplantitis of implant #19 and adjustment of her lower partial denture. Gave pt Rinsinol P.R.N. mouth sore rinse to help with the sore spot on the lower ridge until she is seen by the specialist for her evaluation.
NV: Scale & Fluoride Treatment AFTER #19 has been resolved.
E & I:
yellowing of the skin. angular cheilitis.
bilateral linea alba. Palatal torus and fordyce granules on lower lip and buccal mucosa of lower lip.
smooth, red tongue, painful tongue, pt report loss of taste.
Salivary flow: adequate.
TMD findings: bilateral clicking & popping.
Max opening: 47 mm.
Facial profile: mesognathic.
Angles class: bilaterally class II.
Gingival description:
Free is generalized pale pink with glossy blunted margins with localized erythema, edema on #19.
Attached is generalized pale pink with stippling.
MBI 18%
Perio Exam: generalized probing depths of 2-4 mm. BOP 20%.
Recession: maxillary buccal 2 mm on teeth #5-11. #19 buccal 5 mm.
Furcations: #14 class I, #30 class I, #31 class I.
Mobility: #19 Class III.
Fremitus: none.
Mucogingial problems: none.
MVC Cal. Code: Light/Medium.
OHA status: fair.
PI 25%.
OHI: Had pt demonstrate current oral hygiene routine. Pt demonstrated a heavy hand when brushing and demonstrated a horizontal brushing technique. Pt demonstrated flossing technique and does not create a “C” shape with the floss; she has a straight vertical technique. Advise pt to use an extra soft toothbrush and use a modified bass method for brushing. Recommend pt to ease up on the pressure when brushing due to the recession present. Recommended to pt to floss daily with expanding floss. Explained to pt that removing plaque daily will help tremendously with the amount of gingival bleeding present. Explained what plaque was and how it contributes to periodontal disease. Recommended pt to use an interproximal brush to clean interproximally where there are gaps present due to blunting of gingiva, explained that food may get trapped in these areas and not only contribute to odor but also gingival inflammation. Demonstrated all OHI with recommendations mentioned; pt was able to demonstrate back techniques effectively.
DDS Exam & Periodontal Radiographic Interpretation:
Missing teeth: #1, 16, 17, 23-26, 32. 3rd molars extracted in High School. Lost lower anteriors in the year that she received cancer treatment.
Existing restorations: PFMs & RCT TX on #2, 3, 14, 15, 19, 30, 31. Existing lower partial denture with metal clasps. Existing restorations all margins intact. LPD has staining and calculus build up on lingual surfaces of teeth.
No decay intraorally nor radiographically.
No atypical findings.
Radiographic decay: Mesial and distal of #5 and distal of #13.
Radiolucency at apices: #19 has apical radiolucency, differential dx- periimplantitis, apical abcess, periodontal abcess.
No intrinsic/extrinsic root resorption.
Dilacerated roots: #7.
No radiolucent/radiopaque lesions or foreign objects noted.
Quality of radiographs are adequate to determine periodontal interpretation.
Trabecular pattern is consistent.
Lamina dura is generalized fuzzy.
Alveolar crest is generalized 3-4 mm from the CEJ with localized 5-6 mm from CEJ of #19.
PDL space is consistent with localized widening on #19.
No interradicular radiolucencies noted.
No calculus noted radiographically.
General osseous interpretation is consistent.
ADA II with localized ADA III on implant #19. AAP class generalized slight chronic periodontitis and localized moderate chronic periodontitis due to plaque and calculus.
Critical Thinking
Chief Complaint: “implant is falling out.”
Medical History/Systemic Health: None. Oral Risk Factors: -------
Dental Health Diagnosis:
Perio: Uncontrolled.
Caries: Uncontrolled.
Oral Hygiene: Uncontrolled.
Influencing Cultural and Social Factors: Grew up using hard toothbrushes and admits buying medium toothbrushes presently. Never understood the importance of flossing daily, when she had her periodontal surgery; she cannot remember if they explained it or not and doesn’t recall the hygienists emphasizing floss at her appointments. Although the patient has a healthy and balanced diet, she eats small meals every 3 hours and does not brush or rinse in between meals.
Dental Hygiene Care Plan:
Oral Health Education/Strategies: Oral Health Belief Model.
*If the patient receives better information than what she has previously been given, she will make better decisions about her oral health. The patient must first believe that her current oral health and oral hygiene routine is causing her gingival recession and inflammation. It is also the reason why she has attachment loss.
*Upon explaining the dental hygiene diagnosis the patient will be able to decide if she considers it a serious issue. When the patient believes that it is serious, a successful intervention can be presented to the patient and she can make the decision to follow through with the recommendations. The patient must overcome all barriers to using the intervention.
Instrument selection: paired 204 sickles, paired universals, 7/8 gracey, paired 6/7 sickles, 5/6 gracey, area specific graceys where needed.
Anesthesia: for patient comfort due to recession present on maxillary buccal 2 mm of teeth #5-11.
URQ & ULQ 2% Lido w/epi ASA 0.9 ml. Reevaluations: #19 periimplantitis and lower ridge soreness. Anticipated Treatment Outcomes: Reduce MBI, BOP & PI indices by 10%. Reduce 4 mm pocket depths by 1 mm Referrals given: Periodontist, see Periodontal Exam Findings. General Dentist, see Dental Exam Findings. Recall Interval: 4-6 Week Re-eval. Rationale: To assess if the gingival is healing and responding to scaling and root planning and antimicrobial treatment. Assess pt oral hygiene techniques. Treatment Plan:
Appt. 1
Assessments, Caries Risk Assessment, DDS Exam, 2nd Check-in, PI/OHI. Referrals given for Periodontist and General Dentist.
Appt. 2
Begin treatment after #19 Peri Implantitis has been treated and healed.
URQ w/ anesthesia.
2% Lido w/epi ASA 0.9 ml, NP 0.45 ml.
LRQ
Fluoride Varnish Treatment.
OHI
Appt. 4
4-6 Week Re-Evaluation.
Scale any residual calculus.
Care of Removable Lower Partial Denture
OHI
The patient was seen and treated by the periodontist the same day as her appointment with our clinic.
Below is a picture the Periodontist mailed with his report regarding his treatment of Peir Implantitis of #19. He also sent a thank you note along with the photo. He was glad we caught it before the infection started affecting the neighboring teeth.
My patient today is Ms Martha Vineyard, she is a 71 year old Caucasian female, DOB 3/13/1940. Today is her first visit to our clinic and her chief complaint is her implant is falling out.
Ms Vineyard had her implant placed 9 months ago and had the crown seated 6 months ago with her general dentist in Florida. Ms Vineyard lives in Florida half of the year and in California the other half. Her dentist of record in California retired and she did not care for the new dentist that bought the practice. Ms Vineyard has periodontal maintenance every 4 months. She had an FMX when the crown for her implant was seated 6 months ago and brought a duplicate set with her to the appointment. Her last perio maintenance in Florida was before she had the implant restored and reported that since the crown has been placed 6 months ago, she has not been in for a cleaning due to trying to find a new dentist in California.
Ms Vineyard also wears a lower partial denture that she reports is not fitting like it used to and she has a sore spot on the most anterior aspect of the mandibular ridge.
Ms Vineyard has a history of bleeding gums spontaneously and has cold temperature sensitivity on her maxillary teeth due to recession. She has nonpainful clicking and popping bilaterally, she has had it all her life. She has a history of periodontal surgery on the maxillary arch 10 years ago. She has been wearing her lower partial denture for over 20 years.
Ms Vineyard has no past or present cardiovascular conditions, respiratory condtions, head and neck conditions, gastrointestinal/genitor-urinary conditions.
Ms Vineyard stated she bruises easily and has a history of pernicious anemia. She is presently under the care of her physician in Florida for her anemia diagnosed in 2001; treated with vitamin B12 injections as needed and monitored. Pt stated currently under control and is on a special diet high in fish, cheese, milk, and eggs. She also had breast cancer when she was 51 years old and had chemotherapy and radiation treatment and ultimately had her left breast removed 6 months after her diagnosis with breast cancer and has been in remission since.
She denies having any past or present psychological disorders has never smoked/drank/or taken any drugs. She had her childhood vaccinations later in life when she was in college preparing to be a teacher, including the hepatitis B vaccination series. She had her last flu shot in Sept. 2011. She is not menopausal nor takes any hormones.
Her family has a history of heart disease, her father died at young age from a heart attack. Her mother passed from lung cancer.
Ms Vineyard has no allergies to anything and doesn’t have any additional medical information to share.
She was hospitalized on and off when she was 51 for the chemo and radiation treatment and surgery of the removal of her left breast for cancer within a 6 month period.
She was seen in the emergency room for a sprained ankle when she tripped in a grocery store parking lot at night last year. She made a full recovery.
Ms Vineyard takes 81 mg Aspirin daily.
S: Pt stated she is here for “her implant is falling out.”
O: RMH initial visit. B.P. 114/68, P. 71, R. 15. E & I bilateral linea alba, palatal torus, and fordyce granules on lower lip and buccal mucosa of lower lip.
A: ASA II. ADA II with localized ADA III on implant #19. AAP class generalized slight chronic periodontitis and localized moderate chronic periodontitis due to plaque and calculus. MVC Cal Code light/medium.
P: Gathered assessments, x-ray check, took one PA of #19 implant. DDS Exam, 2nd Check-in, PI/OHI. Referral given to patient to see Periodontist specialist for the evaluation of periimplantitis of implant #19 and adjustment of her lower partial denture. Gave pt Rinsinol P.R.N. mouth sore rinse to help with the sore spot on the lower ridge until she is seen by the specialist for her evaluation.
NV: Scale & Fluoride Treatment AFTER #19 has been resolved.
E & I:
yellowing of the skin. angular cheilitis.
bilateral linea alba. Palatal torus and fordyce granules on lower lip and buccal mucosa of lower lip.
smooth, red tongue, painful tongue, pt report loss of taste.
Salivary flow: adequate.
TMD findings: bilateral clicking & popping.
Max opening: 47 mm.
Facial profile: mesognathic.
Angles class: bilaterally class II.
Gingival description:
Free is generalized pale pink with glossy blunted margins with localized erythema, edema on #19.
Attached is generalized pale pink with stippling.
MBI 18%
Perio Exam: generalized probing depths of 2-4 mm. BOP 20%.
Recession: maxillary buccal 2 mm on teeth #5-11. #19 buccal 5 mm.
Furcations: #14 class I, #30 class I, #31 class I.
Mobility: #19 Class III.
Fremitus: none.
Mucogingial problems: none.
MVC Cal. Code: Light/Medium.
OHA status: fair.
PI 25%.
OHI: Had pt demonstrate current oral hygiene routine. Pt demonstrated a heavy hand when brushing and demonstrated a horizontal brushing technique. Pt demonstrated flossing technique and does not create a “C” shape with the floss; she has a straight vertical technique. Advise pt to use an extra soft toothbrush and use a modified bass method for brushing. Recommend pt to ease up on the pressure when brushing due to the recession present. Recommended to pt to floss daily with expanding floss. Explained to pt that removing plaque daily will help tremendously with the amount of gingival bleeding present. Explained what plaque was and how it contributes to periodontal disease. Recommended pt to use an interproximal brush to clean interproximally where there are gaps present due to blunting of gingiva, explained that food may get trapped in these areas and not only contribute to odor but also gingival inflammation. Demonstrated all OHI with recommendations mentioned; pt was able to demonstrate back techniques effectively.
DDS Exam & Periodontal Radiographic Interpretation:
Missing teeth: #1, 16, 17, 23-26, 32. 3rd molars extracted in High School. Lost lower anteriors in the year that she received cancer treatment.
Existing restorations: PFMs & RCT TX on #2, 3, 14, 15, 19, 30, 31. Existing lower partial denture with metal clasps. Existing restorations all margins intact. LPD has staining and calculus build up on lingual surfaces of teeth.
No decay intraorally nor radiographically.
No atypical findings.
Radiographic decay: Mesial and distal of #5 and distal of #13.
Radiolucency at apices: #19 has apical radiolucency, differential dx- periimplantitis, apical abcess, periodontal abcess.
No intrinsic/extrinsic root resorption.
Dilacerated roots: #7.
No radiolucent/radiopaque lesions or foreign objects noted.
Quality of radiographs are adequate to determine periodontal interpretation.
Trabecular pattern is consistent.
Lamina dura is generalized fuzzy.
Alveolar crest is generalized 3-4 mm from the CEJ with localized 5-6 mm from CEJ of #19.
PDL space is consistent with localized widening on #19.
No interradicular radiolucencies noted.
No calculus noted radiographically.
General osseous interpretation is consistent.
ADA II with localized ADA III on implant #19. AAP class generalized slight chronic periodontitis and localized moderate chronic periodontitis due to plaque and calculus.
Critical Thinking
Chief Complaint: “implant is falling out.”
Medical History/Systemic Health: None.
Oral Risk Factors: -------
Dental Health Diagnosis:
Perio: Uncontrolled.
Caries: Uncontrolled.
Oral Hygiene: Uncontrolled.
Influencing Cultural and Social Factors: Grew up using hard toothbrushes and admits buying medium toothbrushes presently. Never understood the importance of flossing daily, when she had her periodontal surgery; she cannot remember if they explained it or not and doesn’t recall the hygienists emphasizing floss at her appointments. Although the patient has a healthy and balanced diet, she eats small meals every 3 hours and does not brush or rinse in between meals.
Dental Hygiene Care Plan:
- Oral Health Education/Strategies: Oral Health Belief Model.
*If the patient receives better information than what she has previously been given, she will make better decisions about her oral health. The patient must first believe that her current oral health and oral hygiene routine is causing her gingival recession and inflammation. It is also the reason why she has attachment loss.*Upon explaining the dental hygiene diagnosis the patient will be able to decide if she considers it a serious issue. When the patient believes that it is serious, a successful intervention can be presented to the patient and she can make the decision to follow through with the recommendations. The patient must overcome all barriers to using the intervention.
- Recommended OHI: Extra soft toothbrush, modified bass brushing technique, interdental brush, expanding floss, alcohol-free mouth rinse.
Implementation/Hygiene Services:- Instrument selection: paired 204 sickles, paired universals, 7/8 gracey, paired 6/7 sickles, 5/6 gracey, area specific graceys where needed.
- Anesthesia: for patient comfort due to recession present on maxillary buccal 2 mm of teeth #5-11.
URQ & ULQ 2% Lido w/epi ASA 0.9 ml.Reevaluations: #19 periimplantitis and lower ridge soreness.
Anticipated Treatment Outcomes: Reduce MBI, BOP & PI indices by 10%. Reduce 4 mm pocket depths by 1 mm
Referrals given: Periodontist, see Periodontal Exam Findings. General Dentist, see Dental Exam Findings.
Recall Interval: 4-6 Week Re-eval.
Rationale: To assess if the gingival is healing and responding to scaling and root planning and antimicrobial treatment. Assess pt oral hygiene techniques.
Treatment Plan:
Appt. 1
Assessments, Caries Risk Assessment, DDS Exam, 2nd Check-in, PI/OHI. Referrals given for Periodontist and General Dentist.
Appt. 2
Begin treatment after #19 Peri Implantitis has been treated and healed.
URQ w/ anesthesia.
2% Lido w/epi ASA 0.9 ml, NP 0.45 ml.
LRQ
Fluoride Varnish Treatment.
OHI
Appt. 3
ULQ w/ anesthesia.
2% Lido w/epi ASA 0.9 ml, NP 0.45 ml.
Fluoride Varnish Treatment.
LLQ
Fluoride Varnish Treatment.
OHI
Appt. 4
4-6 Week Re-Evaluation.
Scale any residual calculus.
Care of Removable Lower Partial Denture
OHI
The patient was seen and treated by the periodontist the same day as her appointment with our clinic.
Below is a picture the Periodontist mailed with his report regarding his treatment of Peir Implantitis of #19. He also sent a thank you note along with the photo. He was glad we caught it before the infection started affecting the neighboring teeth.